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close this bookThe Condition of Young Children in Sub-Saharan Africa: The Convergence of Health, Nutrition, and Early Education (WB, 1996, 64 p.)
close this folder2. The status of children In sub-Saharan Africa
View the document(introduction...)
View the documentProgress in human development
View the documentPhysical needs: Survival, health, and nutrition
View the documentEducational profile
View the documentEarly interventions, school readiness and subsequent performance
View the documentThe challenge ahead
View the document3. What can early childhood development programs do?
View the documentImproving child quality
View the documentIncreasing the efficiency of primary and secondary school investments
View the documentEnhancing the economic contribution of the child to society
View the documentReducing social inequity
View the documentAddressing the intersecting needs of women and children
View the documentCreating synergistic effects of health, nutrition, and early stimulation

Physical needs: Survival, health, and nutrition

An equal chance to survive is a basic right of all human beings. Yet Sub-Saharan Africa possesses the highest infant mortality rate in the world. Of the 40,000 children under the age of five who die in the world every day, over one-third are Africans, a proportion that is steadily rising. SubSaharan Africa accounts for only 12 percent of the world's population, but nearly 40 percent of child deaths. About 5 million child deaths occur in Sub-Saharan Africa each year. Within Sub-Saharan Africa, infant mortality rates range from a low of 47 per thousand in Zimbabwe to a high of 162 in Mozambique.

Figure 4: UNDP Human Development Index

Figure 5: Infant Mortality Rate (per 1,000 live births)

The under-5 mortality statistics indicate the probability that a newborn baby will die before reaching age 5. This shows the same pattern as that of infant mortality. In 1992, the regional odds of a child dying before the age of 5 were more than one in three (339 per thousand). The odds of early death are twice as high as the world average (173 per thousand) and over four times that of the European and Central Asian rate (75 per thousand). In Mozambique alone, more than half the children (552 out of per thousand) die before turning five.

Figure 6: Under-5 Mortality Rate 1992 (per 1,000 live births)

Many of the same conditions of poverty and stress that place under 5 children at risk of death early in life, later leave them at risk of poor health, malnutrition, and impaired mental, social and emotional development. The absence of proper care and education in the early years have longterm consequences.

Regarding children's health status, although Sub-Saharan Africa has made significant progress, the health indices are still worse than those of any other region. The lack of clean water and safe sanitation are among the most critical determinants of good health. Only about 42 per cent of the Sub-Saharan population had access to safe water in 1993. This rate is the lowest among all the principal regions of the world and about half of the rate of the Arab States and Latin American countries (82 percent). Some countries are worse than others within the region. For instance, only one-tenth of the population in the Central Africa Republic had access to safe water in 1993. Access to sanitation and health services is also limited throughout Sub-Saharan Africa. In 1993, only 26 percent of the population had adequate sanitation, and about 56 percent could count on health services. Without safe water and adequate sanitation, fly-transmitted diseases are dominant in the heat, particularly in urban slum areas. In rural areas, millions of women and children must walk a long distance just to fetch a jar of water. This lack of drinking water locally adds to the already high transport burden for women and children, who are responsible for over 70 percent of transport in terms of time and over 80 percent in terms of effort (Urasa 1990).

Figure 7: Percent of Population With Access to Health Services, Safe Water, and Sanitation

In 1991, only 63 percent of the children in the region had been immunized against tuberculosis and less than 50 percent against DPT (diphtheria, pertussis, and tetanus), polio and measles. This is far short of the 90 percent goal for the year 2000 set at the World Summit for Children. Only 46 percent of children under five have access to oral rehydration therapy (World Bank 1995a). These numbers are strikingly low in comparison to what has been achieved in other developing regions: 94 percent in East Asia and the Pacific, 86 percent in South Asia, 87 percent in the Arab states, and almost 80 percent in Latin America and Caribbean region.

Malnutrition is widespread in Sub-Saharan Africa. Sixteen percent of the babies born in SubSaharan Africa in 1992 suffered from low birth weight, compared to seven percent among highly developed countries (UNDP 1994). Low birth weight, defined as babies who are born weighing less than 2,500 grams, is associated with poor maternal health and malnutrition, and tends to lead to poor growth in infancy and childhood. The proportion of low birth weight babies in the region ranges from a low of 8 percent in Botswana to a high of 21 percent in Burkina Faso.

About 29 million children (30 percent) of the under-5 population are underweight. Children under the age of 5 are considered underweight if they weigh-in at two standard deviations below the median weight for age of the reference population. This rate is almost three times that of the Latin America and Caribbean area and four times that in industrial countries. Within Sub-Saharan Africa, the prevalence of underweight children varies substantially. It ranges from a low of 12 percent in Cd'Ivoire, to as high as 49 percent in Niger, Tanzania, and Mauritania. About 12 countries in Sub-Saharan Africa have an underweight rate exceeding 25 percent.

Figure 8: Percent of 1-year-olds immunized against TB, DPT, and Measles

By the year 2020, virtually each region in the world will experience a reduction in the absolute numbers of underweight pre-school children, with the notable exception of Sub-Saharan Africa. Even an optimistic scenario puts the number of malnourished at about 34 million in the year 2020. Unless the population growth rates (currently at 3 percent) are dramatically reduced, the absolute number of underweight children will rise even if the prevalence rates are kept at present levels in 2020 (Garcia 1994).

Figure 9: Projections of Numbers of Underweight Pre-school Children (millions), by Region, Optimistic Scenario, 2020

Two other indicators associated with malnutrition are 'wasting' and 'stunting.' 'Wasting', or acute malnutrition, refers to the situation where emergencies such as sickness or food shortage cause the child to become underweight relative to height. It is medically defined as children between 12 and 23 months weighing two standard deviations below the median weight for height of the reference population. 'Stunting', also known as chronic malnutrition, refers to a situation where a child, due to insufficient nutrition during infancy, becomes abnormally short relative to age, medically defined as children between 24 and 59 months standing two standard deviations below the median height-for-age of the reference group.

Between 1980 and 1991, approximately 12 percent of 12 to 23 month-olds in SubSaharan Africa were 'wasted.' This proportion is more than three times the incidence in Latin America and the Caribbean (4 percent). Another 42 percent of 24-59 months olds are 'stunted.' Again, this rate is double that of the Latin America and Caribbean (23 percent) region (World Bank 1993; UNDP 1994). The incidence of wasting varied from 2 percent in Zimbabwe to 23 percent in Niger and of stunting from 14 percent in Botswana to 43 percent in Nigeria and Malawi.

Figure 10: Percent of Children Underweight, Wasted, and Stunted, 1991

Malnutrition greatly increases the risk of morbidity which is correspondingly high in SubSaharan Africa. Demographic and Health Surveys (DHS) conducted by the Africa Regional Nutrition and Family Health Analytical Initiative Project between the period 1986-92, show that the average prevalence of diarrhea among children under 2 years is 34 percent. About 1 in 2 Senegalese children under 24 months had diarrhea in the 2 weeks preceding the survey, the highest among the countries surveyed. Most deaths from diarrhea could be prevented by almost cost-free oral rehydration therapy (ORT) and continued feeding. Thirty-six percent were reported to have had a bad fever, and another 31 percent were found to have had a cough or suffered from rapid breathing. Both are major causes of pneumonia, death from which could be prevented by the early prescription of low-cost antibiotics. Other indirect effects of malnutrition include delayed mental development and enrollment in school (Box 6).

A new and further threat to the health status of mothers and children in Sub-Saharan Africa is AIDS. This human immuno deficiency virus is now a formidable threat to Africa's health as well as to its social and economic well-being. In 1992, approximately 6.5 million people were infected by HIV in Sub-Saharan Africa and two-thirds of all new cases are occurring on the continent. With increasing numbers of HIV-infected mothers giving birth to infected children, Africa is being robbed of both its present and its future. An estimated I million (14 percent) of the total HIV-infected people are children, and this number may increase to 2 million by the end of this century.

Box 6: Malnutrition and Delayed Primary School Enrollment

A World Bank paper investigated why children in low income countries often delay primary school enrollment despite the prediction of human capital theory that schooling will begin at the earliest possible age. The study explored a number of explanations for delayed enrollment and tested alternative hypotheses using data from a household survey in Ghana. The estimates, which address a number of previously-ignored econometric issues, strongly support the notion that childhood malnutrition causes delayed enrollment*. A Participatory Poverty Assessment in Tanzania shows how delayed enrollment can be particularly detrimental to girls' education. It drastically reduces the number of years a girl spends in school as she is usually forced to drop out at puberty.

The delays can be caused by illnesses or the perception of parents and teachers that the child is not ready for school.

Source: Glewwe and Jacoby 1992.

Infant mortality rates may be at least 30 percent higher than they would have been in the absence of AIDS, and many children will survive only to enter a more precarious environment upon a parent's death from AIDS. Children who lose their parents to AIDS are often forced to drop out of school to survive. In Tanzania, for instance, the widespread prevalence of AIDS is associated with the withdrawal of girls from school and with marriage at an early age, eroding much of the progress made in female education (Ainsworth and others 1992; Shaeffer 1993).

In sum, a significant proportion of Sub-Saharan African children live in poor health, are malnourished and have either fallen prey or are vulnerable to infectious diseases. Even short-term nutritional deprivation in the early years of life can lead to long-term damage, thus influencing the capacity to learn and grow, and later influencing adult productive capacity. Poverty and lack of information are the main causes of malnutrition and disease. Interventions such as early detection by monitoring growth in childhood and during pregnancy, food supplementation, nutrition and health education, and medical referral of malnourished /sick children contribute to the reduction of child mortality and malnutrition.